§ 2800.251. Resident records.
(a) A separate record shall be kept for each resident.
(b) The entries in a resident’s record must be permanent, legible, dated and signed by the staff person making the entry.
(c) The residence shall use standardized forms to record information in the resident’s record.
(d) Separate resident records shall be kept on the premises where the resident lives.
(e) Resident records shall be made available to the resident and the resident’s designated person during normal working hours. Resident records shall be made
available upon request to the resident and the resident’s designated person.
§ 2800.252. Content of resident records.
Each resident’s record must include the following information:
(1) Name, gender, admission date, birth date and Social Security number.
(2) Race, height, weight at time of admission, color of hair, color of eyes, religious affiliation, if any, and identifying marks.
(3) A photograph of the resident that is no more than 2 years old.
(4) A language, speech, hearing or vision need which requires accommodation or awareness of during oral or written communication.
(5) The name, address, telephone number and relationship of a designated person to be contacted in case of an emergency.
(6) The name, address and telephone number of the resident’s physician or source of health care.
(7) The current and previous 2 years’ physician’s examination reports, including copies of the medical evaluation forms.
(8) A list of prescribed medications, OTC medications and CAM.
(9) Dietary restrictions.
(10) A record of incident reports for the individual resident.
(11) A list of allergies.
(12) Documentation of health care services and orders, including orders for the services of visiting nurse or home health agencies.
(13) The initial assessment, the preliminary support plan and the most current version of the annual assessment.
(14) A final support plan.
(15) Applicable court order, if any.
(16) The resident’s medical insurance information.
(17) The date of entrance into the residence, relocations and discharges, including the transfer of the resident to other residences owned by the same legal entity.
(18) An inventory of the resident’s personal property as voluntarily declared
by the resident upon admission and voluntarily updated.
(19) An inventory of the resident’s property entrusted to the administrator for safekeeping.
(20) The financial records of residents receiving assistance with financial management.
(21) The reason for termination of services or transfer of the resident, the date of transfer and the destination.
(22) Copies of transfer and discharge summaries from hospitals, if available.
(23) If the resident dies in the residence, a copy of the official death certificate.
(24) Signed notification of rights, grievance procedures and applicable consent to treatment protections specified in § 2800.41 (relating to notification of
rights and complaint procedures).
(25) A copy of the resident-residence contract.
(26) A termination notice, if any.
(27) A record relating to any exception request under § 2800.229 (relating to excludable conditions; exceptions).
(28) Ongoing resident progress notes.
§ 2800.253. Record retention and disposal.
(a) The resident’s entire record shall be maintained for a minimum of 3 years following the resident’s death, discharge from the residence or until any audit or
litigation is resolved.
(b) Records shall be destroyed in a manner that protects confidentiality.
(c) The residence shall keep a log of resident records destroyed on or after January 18, 2011. This log must include the resident’s name, record number, birth
date, admission date and discharge date.
(d) Records required under this chapter that are not part of the resident records shall be kept for a minimum of 3 years or until any audit or litigation is
§ 2800.254. Record access and security.
(a) Records of active and discharged residents shall be maintained in a confidential manner, which prevents unauthorized access.
(b) Each residence shall develop and implement policy and procedures addressing record accessibility, security, storage, authorized use and release and
who is responsible for the records.
(c) Resident records shall be stored in locked containers or a secured, enclosed area used solely for record storage and be accessible at all times to the
administrator, the administrator’s designee, or the nurse involved in assessment and support plan development and upon request, to the Department or representatives of the area agency on aging.